COVID‐19 vaccination coverage and vaccine hesitancy among Australians with disability and long‐term health conditions

Abstract Issue Addressed COVID‐19 vaccination is the cornerstone of managing Australia's COVID‐19 pandemic and the success of the vaccination program depends on high vaccination coverage. This paper examined differences in COVID‐19 vaccination coverage and vaccine hesitancy for people with disability, long‐term health conditions, and carers – subgroups that were prioritised in Australia's vaccination program. Methods Using data from 2400 Australians who participated in two waves of the Taking the Pulse of the Nation survey in April and May 2021, we described vaccination coverage and hesitancy among people with disability, severe mental health conditions, severe long‐term health conditions, frequent need for assistance with everyday activities, and carers. Results Vaccination coverage was estimated to be 8.2% in the population overall and was similar for people with disability, those with frequent need for assistance, and carers. It was higher for people with severe long‐term health conditions (13.4%) and lower for people with severe mental health conditions (4.3%). Vaccine hesitancy was high overall (35.6%) and was similarly high across the priority groups, with only small differences for people with disability, severe long‐term health conditions and frequent need for assistance. Conclusions This study highlights a lack of difference in vaccination coverage for people with disability, long‐term health conditions, and carers compared to the general population. So what? Sub‐optimal vaccination coverage for people in the priority groups leaves many people at significant risk of serious disease or death if exposed to COVID‐19, particularly in light of easing of disease‐control restrictions across Australia and the emergence of new variants.

. People with long-term health conditions including serious mental illness, people with intellectual disability and people who required assistance with activities of daily living were prioritised. 2 These groups also included workers providing support in aged-care or to people with disability, as well as informal carers who provide unpaid support to people who needed assistance with activities of daily living. Therefore, despite prioritising people at highest risk, some priority groups have sub-optimal vaccination coverage which poses a threat to individual and population immunity. 5 People with disability and long-term health conditions are at high risk of serious disease or death if infected with COVID-19 due to comorbidities, living conditions, behavioural factors and socio-economic deprivation and may have higher risk of infection and transmission because of their need for care or assistance and increased likelihood of living in congregate care settings. 6,7 But there is a lack of data describing COVID-19 vaccination rates for people with disability and longterm health conditions because disability data are not routinely collected in Australia. Data from government and media reports from mid-2021 showed that there were significant delays in the rollout of the vaccine among people living in aged-care and disability residences and the workers who support them. [8][9][10] Since January 21, 2022, data have been routinely reported on vaccination coverage for NDIS participants, 11 demonstrating lower vaccine coverage compared to the general population, but this only represents 10% of Australians with disability. There is a lack of data on vaccination coverage for the 90% of Australians with disability who are not eligible for the NDIS.
There are several potential causes of low vaccination coverage for people with disability including physical availability of vaccines, geographic accessibility, availability of accessible information about vaccine availability and eligibility, and vaccine hesitancy. 5  COVID-19 vaccine in younger age-groups. 12,13 Vaccine hesitancy, the delay in the acceptance or refusal of vaccines, 5,14,15 is also a likely cause of inequalities in vaccination coverage.
Australian research has demonstrated high levels of vaccine hesitancy in the population, 16 consistent with rates of vaccine hesitancy across other high-income countries ranging from 7% to 77.9%. 17 An Australian survey conducted in January 2021 before the vaccination program was implemented, found that only 44% of Australians reported that they would definitely get vaccinated, with 35% reporting they would probably get vaccinated, 8% reporting they would probably not get vaccinated, and 13% reporting they would definitely not get vaccinated. 18 More recent data from a longitudinal survey investigating the impacts of the COVID-19 pandemic on Australian households which collected data on disability and included questions about vaccine hesitancy in five waves of the survey between December 2020 and July 2021 found that levels of vaccine hesitancy were very similar between people with and without disability, though vaccine hesitancy was higher for people with psychosocial disability. 19 Australia experienced a surge in COVID-19 infections at the end of 2021 alongside the easing of disease-control restrictions and the emergence of the Omicron variant, which highlights the ongoing need for high COVID-19 vaccination coverage. Despite high vaccination coverage in the population overall, waning vaccine immunity and suboptimal vaccination coverage in some subgroups of the population pose a threat to individual and population immunity. 5 20,21 It is also critical for understanding the potential impacts of easing restrictions on severe outcomes associated with COVID-19 infection, which will be distributed inequitably across different subgroups of the population.
This paper fills a gap in our knowledge about vaccination coverage and vaccine hesitancy among people with disability and long-term health conditions, and carers in Australia with the aim of identifying groups who require better targeting to improve vaccination coverage and understanding the causes of sub-optimal vaccination coverage.
Using data from 2400 Australians who participated in Taking the Pulse of the Nation survey in April and May 2021, at the start of the COVID-19 vaccination program, we describe vaccination coverage and hesitancy among people with disability, people who reported living with a severe mental health condition, a severe long-term health condition, and those requiring frequent assistance with everyday activities. We also report vaccination coverage and hesitancy for people who provide paid or unpaid care to someone in one of the priority groups.

| METHODS
We used data from Taking (Table 1).
In these two waves of the survey, a question was included about presence of disability, defined as "a long-term health condition, impairment or disability that restricts you in your everyday activities and has lasted (or is likely to last) for 6 months or more." Additional questions were included to identify whether people had a "severe mental health condition," "a severe long-term health condition (eg, heart disease, diabetes, poorly controlled blood pressure, severe obesity)," or "required frequent assistance with everyday activities (eg, eating, dressing, mobility)," to align with the vaccine priority group eligibility criteria. A question was also included to identify people who "pro- already," "yes," "no," and "don't know." People were identified as being vaccinated if they responded that they had had the vaccine. Therefore We estimated the proportion of the sample who were vaccinated and who were vaccine hesitant, for the whole sample (both waves combined) and for exposure groups of interest (people with disability, severe mental health conditions, severe long-term health conditions, people requiring frequent assistance with everyday activities, and people who were paid or unpaid carers) for participants who had no missing data on the variables of interest. Differences between groups were evaluated using 95% confidence intervals. 24 We disaggregated the results by age group and gender.

| RESULTS
The two waves of the survey included 2400 participants, of which 7.4% were vaccinated and 35.6% were vaccine hesitant (

| Vaccination coverage
There was evidence that the proportion of people who had been vaccinated was higher for people with severe long-term health conditions (13.4%) compared to those without severe long-term health conditions (6.9%), with nonoverlapping confidence intervals (Table 3). There was some evidence of a difference for people with severe mental health conditions who had lower vaccination coverage (4.3%) T A B L E 3 Proportion of the study population who had received at least one dose of COVID-19 vaccine, by priority group, age and gender, n = 2400 There was no evidence of a difference for people with disability (8.9%), people in need of frequent assistance with everyday activities (7.1%), and carers (8.9%), and lower for people with severe mental health conditions (4.3%).
Vaccination coverage was higher for people aged 65 years and older (30.5%) compared to those aged 18 to 64 years who had very low vaccination coverage (2.6%), even for people in the vaccine priority groups, ranging from 1.2% to 4.2%. Vaccination coverage was similar for men (9.0%) and women (7.4%), and the patterns across the priority groups were broadly consistent with the sample overall when disaggregated by gender.

| Vaccine hesitancy
Overall vaccine hesitancy was high, with 35.6% of the sample estimated to be hesitant to receive the vaccine (Table 4). Vaccine hesitancy was found to be high across the priority groups, ranging from 24.2% for people with frequent need for assistance to 36.1% for people with severe mental health conditions. There was evidence of differences between the groups, with lower vaccine hesitancy for people with severe long-term health conditions and frequent need for assistance compared to those without severe long-term health conditions and frequent need for assistance, and weak evidence of a difference for people with disability compared to those without disability.
There were substantial differences by age group and gender.
Vaccine hesitancy was higher for people aged 18 to 64 years (39.7%) compared to those aged 65 years and older (19.3%) and patterns within each age group were similar across the priority groups.
There was evidence than vaccine hesitancy was higher for women than men (39.9% versus 31.1%), a pattern which was generally consistent across most of the priority groups with the exception of people with severe long-term health conditions and frequent need for assistance.

| DISCUSSION
The findings of this study suggest that vaccination coverage was similar between people in the overall sample and the majority of the priority groups examined in this study, including people with disability, people with frequent need for assistance and people who were carers.
There was some evidence that vaccination coverage was higher for people with severe long-term health conditions and lower for people with severe mental health conditions. Vaccination coverage was strikingly low for younger people in all priority groups. Given that people in these priority groups were eligible to receive the vaccine at the time of the survey, the lack of difference in vaccination coverage between young people in the priority groups and the overall sample is surprising and of concern.
Despite people with disability being prioritised for vaccination, the Royal Commission hearing in May 2021 highlighted the low rates of vaccination for people with disability. 25 The results of this study were consistent with the findings of the Royal Commission, indicating low vaccination coverage and little evidence of a difference in T A B L E 4 Proportion of the study population who were vaccine hesitant, by priority group, age and gender vaccination coverage for people with disability and long-term health conditions compared to those without disability and long-term health conditions.
Our study found that vaccination coverage was higher for people aged 65 years and older compared to those aged 18 to 64 years.
Older adults aged 70 years and older became eligible for vaccination in phase 1b, which explains the higher coverage among older people in the sample, driven by age-based eligibility. This suggests the pres- Our study had a number of strengths. This is the first study to examine vaccination coverage and hesitancy for people with disability and long-term health conditions in Australia, using definitions aligning closely with the vaccine priority groups. The sample was large enough to identify people in all the priority groups of interest, including analyses disaggregated by age group and gender. There were also limitations. We did not examine all vaccine priority groups. There was insufficient data to examine occupational vaccine priority groups such as healthcare workers, though it would be valuable to gain insights into vaccination coverage and hesitancy in these groups who were also eligible to receive the vaccine. Furthermore, there was limited data collected on people's health conditions, therefore we were unable to examine vaccination and vaccine hesitancy for people with specific health conditions or those with multiple conditions. We only examined two broad age groups because there were too few younger people in the priority groups to disaggregate the age groups further.
As a result, we could not examine people aged younger than 50 years separately, for whom there were different recommendations for use of the Cominraty (Pfizer/BioNTech) vaccine. Furthermore, due to the age categories used in the survey, it was not possible to identify people aged 70 years and above to align with age-based eligibility. We Vaccine hesitancy was found to be similar between people with disability and long-term health conditions compared to the overall sample, suggesting that low vaccination coverage is likely to be caused by barriers to accessing vaccination rather than high vaccine hesitancy. There remains a lack of understanding of the barriers faced by people in these priority groups. Further research is needed to understand the barriers to accessing COVID-19 vaccination experienced by Australians with disability and long-term health condition, to generate the information that is needed to devise effective strategies to improve uptake by ensuring these populations have easy access to COVID-19 vaccines such as accessible vaccination hubs, in-reach into workplaces and homes, and codesigned communication strategies.

AUTHOR CONTRIBUTIONS
ZA, AK and EE conceived the study and designed the questions for the TTPN Survey. ZA analysed the data and results were reviewed and interpreted by ZA, AK and EE. ZA and AK wrote the manuscript, which was reviewed by EE.

This study was funded by a National Health and Medical Research
Council Centre of Research Excellence grant (1116385). The funders of the study had no role in the design of the study, data collection, data analysis, data interpretation, or writing of the manuscript.